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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Michael Upped
COUNTY Dutchess
CITYrrOw~::PfJnoer
DISTRICT 1
NUMBER
REGISTER 138
NUMBER
1. A. FUll NAME
FIRST
CURRENT SURNAME
MIDDLE
Q.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)UrL-n.Tl~3
D. SOCIAL SEC~'ER
2. RESIDENCE A. ark B. westcheSter
(STATE) ~ (COUNTY)
C. CHECK ON~ _~ _Q!;D' TOWN D VILLAGE
~~~CIFY voruanat anor
D. STREET ADDRESS 25 Bevetly Raed
10!567
ZIP
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 2i:
3. A. AGE 26 3B. DATE OF BIRTH 02 /
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Construction Estimstar
B. TYPE OF INDU~Y ~SilN~ F. I. Gless
5. PLACE OF BIRTH e , York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME John Ec:Mard Uppert
6. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME ~
B. COUNTRY OF BIR~ ~nnette Gllllm
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV't5CE CIVIL ANtfLMENT
"
Y/~m
YEAR
DEtJH
B. HOW DID LAST MARRIAGE END? (3) DDIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL l'/
11. A.
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
FULL NAME Dare Jane Incorvaia
FIRST MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), l[j~
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) oti;l-titi-8921
D. SOCIAL SE~~ER
12. RESIDENCE A. ark B. DutCheSS
(STATE) " (COUNTY)
C. CHECK OWIi.,-~~!.'!. D TOWN D VILLAGE
AND VVIIppm~
SPECIFY 18 ~I Or1Yc 12S0
D. STREET ADDRESS ZIP .,;
E. IS RE~CE WITHIN LIMITS OF CITY OR INCORPORATff5llLAGE? D rr~79 NO
13. A. AGE 13.6. DATE OF BIRTH ,P4 If!:.
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Secretary
B. TYPE OF INDU~ H~ y.tley GI_
15. PLACE OF BIRTH ., New 'Votk
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Angel Fl'
A. NAME a. ncofV..
B. COUNTRY OF BIRTH~
17. MOTHER
A. MAIDEN NAME UncII J. Plgano
B. COUNTRY OF BIRTHU & ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'ljRCE CIVIL A~LMENT
D~TH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
D D
D D
D D
o 0
gal impediment exists
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say that to 1mb be
as to my right to enter into the marri stat
,
21. SIGNATURE OF GROOM ~
US
23. SUBSCRIBED AND SWORN TO BEF"/bE ME
SIGNATURE OF TOWN OR CITY ClEili< ~ DATE
This license authorizes the marriage in New York Sta authorized by New York Domestic
RelatiDns Law !l11 to perfDrm marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremDny.
~ 24. TOWN OR CI:rdi1irC. M8steIsan 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME(PRIN~) C~~ 11/14l2OO5 TIME
SEAL SIGNATURE ~ ~~ ~ - DATE
'-v-' M'2UWIi Rd, ppinger Falls, NY 12590 02:58 AM 11
STREET CITYrrOWN STATE ZIP PM
~~~R~~~Ri~~~ IO~O~~N~EE~ 26. SOLEMNIZATION OCCURRED 27. TY;; OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
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29. OFFICIANT
TITLE
DATE
SIGNATURE ~
DOH-98 (11/98)
.
MONTH
YEAR
MONTH
YEAR
15
2005
01
13 2006
If. c. P~/Es"-
III:L~ /os-
. . 1.2S?o
ZIP
31. WITNESS TO CEREMONr
NAME (PRINT)
SIGNATURE ~
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~/fG=SS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF D. TOWN OF ~LAGE OF
SPECIFY -'J1Jft1Jff~~K~ ffrLLS